Request for Access Accommodations

* indicates a required field

Student Information

Please enter your information
ex. C01234567
Please use your university issued email address
(###) ###-###
Date of Birth
On which campus(es) will you be attending classes?Required



















Specific Accommodation Information

My diagnosed disability falls into the following category (mark all that apply).Required
Are you currently being treated for your disability?Required
medication, vocational rehab, counseling, equipment, or software
Testing, lecture, accessing faculty, reading, writing, computer access
For example, family commitments, work commitments, transportation, etc.
Documentation Guidelines

Choose the link below to review Disability Support Services Documentation Guidelines.
https://www.ivytech.edu/dss/

Upload supporting document(s)

Release of Information

You may authorize the Office of Disability Support Services (DSS) to communicate with the following individuals, agencies, or service providers regarding your access accommodations and services. This release will remain in effect until you rescind the authorization.
Ivy Tech faculty and staff such as Advisor, Financial Aid, Registrar, Test Center, etc.Required
External Constituents such as diagnosing or treating physician or school that previously provided servicesRequired
External constituents such as Vocational Rehabilitation, Textbook Publisher, etc.Required
Source of Documentation such as treating or diagnosing physician or school that previously provided servicesRequired
Name, relationship, phone number